Case Study · Payment Integrity
A licensed home-care agency was validating caregiver hours by hand, across a wall of spreadsheets. Our team replaced it with a time-aware control system that checks every hour against what was actually authorized, before a single dollar is paid.
Prevented / month
Leakage & clawbacks caught before payout
Payroll QA cycle
~75% less clerk time, every run
Recovered / year
Estimated, at current volume
Enforcement
Validation rules run on every visit, no skips
The situation
Every pay period, a clerk sat down with progress notes on one side and a sprawl of authorization spreadsheets on the other, and reconciled them by hand. Were these hours inside the certification period? Was this the assigned caregiver on that date? Did the week exceed the authorized limit? Had this visit already been paid? Was the client on hold?
Each of those questions is a place money leaks: an over-authorized week, a duplicate paid twice, a visit outside the cert period that triggers a clawback later. Answered by hand, across eight hours, at the end of a long month, mistakes were inevitable and expensive. The spreadsheets couldn't answer "what was true on the service date", only what was true today.
What we built
The system sits upstream of payroll as a gatekeeper. Every hour of care is checked against the authorization that governed it on the date it was delivered. Anything that fails is held and surfaced for review, with the reason attached.
i.
Every check uses the rules that were in force on the service date, not today's. Past pay periods always validate against what was actually true then, so late submissions and back-dated corrections stay correct.
ii.
Cert period, correct caregiver, authorized day, weekly-hour ceiling, active holds, and duplicate payments. All six run on every visit record. Blocks are hard; nothing slips through on a busy day.
iii.
Scanned progress notes are read by AI into structured visit records. Low-confidence fields are flagged for a clerk to confirm against the image. Submission is blocked until they do. Speed without blind trust.
iv.
Certification windows and holds are first-class. The system flags what's expiring before it lapses, so authorizations don't quietly run out and turn billable work into unpaid work.
The checks
Every visit is tested against all six, every run. No shortcuts, no skips. Five block a payout outright; one flags a visit for a human to look at. Each maps to a specific way dollars used to escape.
No hour is paid if a record already exists for that patient, date, and care type. Catches the double-entry that manual review misses at hour seven.
Blocks payoutHours are summed across the true Sunday–Saturday week and held the moment they exceed the authorized limit, before the overage is ever paid.
Blocks payoutA service date beyond the certification period is stopped, the classic source of denied claims and after-the-fact recoupment.
Blocks payoutIf the client was on an active hold on the service date, the visit doesn't pass. Those hours aren't reimbursable and shouldn't reach payroll.
Blocks payoutThe hours must belong to the caregiver actually assigned on that service date. Unassigned work is unbillable work, caught before it's paid.
Blocks payoutVisits landing outside the authorized days of the week are surfaced for a clerk to confirm. A flag, not a hard stop, because these are sometimes legitimate.
Flags for reviewBefore & after
Before · by hand
After · the control system
The win isn't that payroll got faster. It's that money which used to walk out the door, quietly, in ones and twos, every single run, now doesn't.The outcome, in one line
Why this generalizes
Strip away the domain and the shape is universal: high-volume work, validated by hand against authorizations and policy, right before money changes hands. Wherever that describes an operation, the same control layer recovers leakage and collapses the review cycle.
Claims adjudication, medical-billing QA, and payment integrity are the exact same problem: validate each claim of value against the policy, authorization, and history that governed it, before money leaves. OKEMA brings this event-based, point-in-time control approach to insurers, banks, and telecoms.
See Claims Intelligence → See Fraud Intelligence →A focused working session: we map where money escapes between work-done and paid, and size what a control layer would recover on your book.